Problem Solver:

The Compression Conundrum

Why patients fail to comply with compression treatment and how providers can help them.

• By David Kopf
• Jan 01, 2011

Compression providers often find themselves in a Catch 22: patients need to comply with their compression therapy, yet often that very therapy can lead to non-compliance. Fortunately, there are some common problems patients have, and some common approaches providers can take to solve them

Compression is used to treat various conditions, including foot swelling, mild edema, varicose veins, thrombosis, varicosities of varying severities, and circulation problems from diabetes. So, a variety of patient groups depend on the therapy, such as geriatric patients, those with diabetes, lymphedema and post-surgery patients. Compression garments provide this treatment by delivering support and increased circulation to affected limbs and other areas of the body.

A Tight Squeeze
Compression is graded in millimeters of mercury and can range from 15-50 mmHg; the higher the compression, the tighter the garment. Lighter compression products start out at 15-20 mmHg, which are for tired, achy legs, mild edema, varicose veins and foot swelling. This level of pressure can also help to prevent vein thrombosis. Higher levels of pressure such as 20-30 mmHg is for severe varicosities, for open face ulcers, moderate edema and post surgery. For people who have ulcers, lymphatic edema and varicosities, they typically need 30-40 mmHg.

Suffice it to say that compression garments are very tight, and for some patients, this can cause problems that lead to non-compliance.

“It’s a pretty big issue,” says Claudia Boyle, president and owner of compression provider Van Driel’s Medical Support Wear. “A lot of patients have difficulty partly because it’s something that has to be done on a daily basis, so it’s a big change in routine; partly because of the expense; and partly because there are application and comfort issues.”

Fitting is a central issue. Simply put, compression garments are hard to get on, and many patients have reach issues, or strength issues, “and they often say ‘I just can’t get this on,’” Boyle says. “Or off. Sometimes getting them off is the bigger problem.”

This is related to comfort. If a stocking is a difficult fit this can lead to comfort issues, as there can be digging or binding. And comfort is an issue that truly varies from patient to patient.

“You might have someone who finds a stocking tremendously uncomfortable or even painful,” Boyle says. “There’s almost always a stocking that can be more comfortable, but it’s sometimes more expensive.”

And expense can get to be a big issue for compression patients since good compression stockings can run fairly high. The more serious the condition or unusual the shape, the more the patient will need an expensive stocking. Higher end compression garments can run as much as $50 to $100. “And that tends to be for the people who need them the most,” Boyle says.

However, insurance reimbursement is uneven. Many insurance companies exclude coverage of compression almost specifically, and Medicare, most of the time, does not pay for them. Given that compression garments wear out, the costs to the patient can quickly mount.

“Pretty much all elastic compression garments have a four to six months’ life expectancy per stocking,” Boyle says. “That’s per set. So if you have a couple pair to go through, you can double that.”

Fortunately there are some common threads between specific patient groups and common problems. This can help compression providers zero in on compliance issues and solutions.

“Seniors typically have application issues,” Boyles says. “They have trouble bending, or there’s arthritis in the hands, or it’s along those lines. Younger folks might have varicose veins, or lymphedema patients’ complaint is often about the appearance of the stocking. Sometimes diabetic patients have complaints about the toe of the stocking; so we have open versus closed-toe options.”

Compliance Solutions
But, while there are some common threads, no two patients are exactly alike, so the solution will often be tailored to that patient’s needs. Providers must have a “bag of tricks” for addressing patients’ compression compliance issues.

If cost is an issue, there are budget lines of garments, and even the better lines of compression garments typically offer budget options that still deliver quality that will hold up to use. However, those budget items might have fewer sizing options, Boyle notes.

When it comes to application issues there are a number of devices that can assist patients in putting on garments. Frames that stretch the garment out, allowing the patient to easily pass the affected limb through the garment are particularly useful in fostering compliance. Also, there are slides for open and close stockings and rubber mats that can be “tremendously helpful” for fitting garments, Boyle says.

“A combination of a couple of those solutions can go a long way toward getting the stocking on,” she adds.

And sometimes compliance can be an issue of compromise. A trade-off for a lower level of compression can lead to a higher level of compliance.

“If we see a patient that is really struggling to fit the level of compression the doctor has prescribed for them, it really makes good sense to contact the doctors and say ‘We’re going to have a compliance issue because the stocking isn’t going to be worn; can we drop down a compression grade or two?’” Boyle explains. “Sometimes just a more realistic approach is a better way to start.”

This article originally appeared in the January 2011 issue of HME Business.